INTRODUCTION:

Scientists at the Centers for Disease Control and Prevention (CDC) are tracking multiple cases of monkeypox that have been reported in several countries that don’t normally report monkeypox, including the United States.¹

CDC is working with state and local health officials to identify people who may have been in contact with individuals who have tested positive for monkeypox, so they can monitor their health.

Dr. Abraham, the Director of ICMR stated in an interview that “Monkeypox is not as transmissible as the Covid-19 virus and the present outbreak gives no cause for undue panic. Transmission between humans takes place through close contact with respiratory secretions (large droplets), skin lesions, or recently contaminated objects. Hence, health care workers, members of households, and other close contacts of active cases of monkeypox are at increased risk”.

Moreover, the World Health Organisation Country Office for India has sought the assistance of India’s ICMR-National Institute of Virology, Pune help to test suspected cases of monkeypox for the south-east Asia region (SEAR) member-states.

Monkeypox:

Monkeypox is a viral zoonotic disease that occurs primarily in tropical rainforest areas of

Central and West Africa and is occasionally exported to other regions.

Monkeypox is transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets and contaminated materials such as clothing, bedding, or other items used in healthcare settings.²

In most cases, people typically recover within two to four weeks without needing to be hospitalized. In some cases, however, monkeypox can also be fatal.

The pathogen:

Monkeypox virus is an enveloped double-stranded DNA virus that belongs to the Orthopoxvirus genus of the Poxviridae family. There are two distinct genetic clades of the monkeypox virus: the central African (Congo Basin) clade and the west African clade. The Congo Basin clade has historically caused more severe disease and was thought to be more transmissible. The geographical division between the two clades has so far been in Cameroon, the only country where both virus clades have been found.¹

Natural host of Monkeypox virus:

Various animal species have been identified as susceptible to monkeypox virus. This includes rope squirrels, tree squirrels, Gambian pouched rats, dormice, non-human primates and other species. Uncertainty remains on the natural history of monkeypox virus and further studies are needed to identify the exact reservoir(s) and how virus circulation is maintained in nature.³

Outbreaks:

Human monkeypox was first identified in humans in 1970 in the Democratic Republic of the Congo in a 9-month-old boy in a region where smallpox had been eliminated in 1968. Since then, most cases have been reported from rural, rainforest regions of the Congo Basin, particularly in the Democratic Republic of the Congo and human cases have increasingly been reported from across central and west Africa.

Since 1970, human cases of monkeypox have been reported in 11 African countries: Benin, Cameroon, the Central African Republic, the Democratic Republic of the Congo, Gabon, Cote d’Ivoire, Liberia, Nigeria, the Republic of the Congo, Sierra Leone and South Sudan. The true burden of monkeypox is not known. For example, in 1996–97, an outbreak was reported in the Democratic Republic of the Congo with a lower case fatality ratio and a higher attack rate than usual. A concurrent outbreak of chickenpox (caused by the varicella virus, which is not an orthopoxvirus) and monkeypox was found, which could explain real or apparent changes in transmission dynamics in this case. Since 2017, Nigeria has experienced a large outbreak, with over 500 suspected cases and over 200 confirmed cases and a case fatality ratio of approximately 3%. Cases continue to be reported until today.

Monkeypox is a disease of global public health importance as it not only affects countries in west and central Africa, but the rest of the world. In 2003, the first monkeypox outbreak outside of Africa was in the United States of America and was linked to contact with infected pet prairie dogs. These pets had been housed with Gambian pouched rats and dormice that had been imported into the country from Ghana. This outbreak led to over 70 cases of monkeypox in the U.S. Monkeypox has also been reported in travelers from Nigeria to Israel in September 2018, to the United Kingdom in September 2018, December 2019, May 2021 and May 2022, to Singapore in May 2019, and to the United States of America in July and November 2021. In May 2022, multiple cases of monkeypox were identified in several non-endemic countries. Studies are currently underway to further understand the epidemiology, sources of infection, and transmission patterns.

Human monkeypox from 1981 to 1986 in the DRC identified 338 cases. The case-fatality rate was 9.8% for persons not vaccinated with vaccinia vaccine, which was about 85% efficacious in preventing human monkeypox. The secondary attack rate in unvaccinated household members was 9.3%, and 28% of case-patients reported an exposure to another case-patient during the incubation period.

Case Report:

July 2022 – INDIA:

India on 14th July confirmed its first monkeypox case in Kerala - a 35-year-old man from Kollam who returned from the UAE. Kerala government said the patient's condition is now stable and nearly 15 people who had come in his contact have been identified.

November 2021 – Travel Associated Case:

The Centers for Disease Control and Prevention (CDC) and the Maryland Department of Health confirmed on November 16, 2021 a case of monkeypox in a U.S. resident who recently returned from Nigeria to the United States. CDC is supporting state and local health officials, airline and travel industry partners, and other stakeholders to identify people who had possible contact with the patient. Because it can take up to 21 days for symptoms to develop after infection, contacts are being asked to monitor their health for that amount of time. CDC will continue to collaborate with partners to ensure the success of this investigation to help prevent additional cases of monkeypox in the United States.

July 2021 – Travel Associated Case:

CDC and the Texas Department of State Health Services confirmed on July 15, 2021 a case of human monkeypox in a U.S. citizen who traveled from Nigeria to the United States on two commercial flights. CDC supported state and local health officials to identify more than 200 people who had possible contact with the patient. Contacts were asked to monitor their health for 21 days. In early September, 21 days had passed without additional cases identified, and the monitoring period for the remaining contacts ended. Strong collaboration between CDC, state and local health departments, airline and airport partners, and other stakeholders involved in this investigation helped to prevent additional cases of monkeypox in the U.S. related to this case.¹

2003 Outbreak from imported Mammals:

In 2003, forty-seven confirmed and probable cases of monkeypox were reported from six states—Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin. All people infected with monkeypox in this outbreak became ill after having contact with pet prairie dogs. The pets were infected after being housed near imported small mammals from Ghana. This was the first time that human monkeypox was reported outside of Africa.

Monkeypox and India travel restrictions:

Currently, India has not established any travel restrictions to prevent the spread of Monkeypox. However the country’s top health research arm is closely monitoring the global surge of monkeypox virus and evaluating the possible options. The states are taking all the necessary precautions with the Mumbai civic body keeping a separate 28-bed ward ready at the Kasturba Hospital for the isolation of suspected patients.

The Ministry of Health and Family Welfare (MoHFW) has advised individuals having history of travel within last 21 days to any of the affected countries to stay monitor their health closely, especially those with an unexplained acute rash or other symptoms such as fever, headache, body aches, swollen lymph nodes, and weakness.

The Health Ministry in India also advised travellers to avoid close contact with sick people, including those with skin lesions or genital lesions. The health authorities in India have also warned people against encountering dead or live wild animals such rodents and non-human primates (monkeys, apes) or eating or preparing meat from wild game (bushmeat), using products derived from wild animals from Africa.

The authorities have further stated that for now, they are adopting a wait-and-watch policy. Two of the country’s Institute laboratory groups are ready to do the testing, and the country is well equipped and prepared.⁵

How it’s spread:

Monkeypox spreads in different ways. The virus can spread from person-to-person through:

direct contact with the infectious rash, scabs, or body fluids respiratory secretions during prolonged, face-to-face contact, or during intimate physical contact, such as kissing, cuddling, or sex touching items (such as clothing or linens) that previously touched the infectious rash or body fluids pregnant people can spread the virus to their fetus through the placenta It’s also possible for people to get monkeypox from infected animals, either by being scratched or bitten by the animal or by preparing or eating meat or using products from an infected animal.

Transmission can also occur via the placenta from mother to fetus (which can lead to congenital monkeypox) or during close contact during and after birth. While close physical contact is a well-known risk factor for transmission, it is unclear at this time if monkeypox can be transmitted specifically through sexual transmission routes. Studies are needed to better understand this risk.

Signs and Symptoms:

The incubation period (interval from infection to onset of symptoms) of monkeypox is usually from 6 to 13 days but can range from 5 to 21 days.

The infection can be divided into two periods:

The Invasion Period:

(lasts between 0–5 days) characterized by fever, intense headache, lymphadenopathy (swelling of the lymph nodes), back pain, myalgia (muscle aches) and intense asthenia (lack of energy). Lymphadenopathy is a distinctive feature of monkeypox compared to other diseases that may initially appear similar (chickenpox, measles, smallpox)

The Skin Eruption Period:

Usually begins within 1–3 days of appearance of fever. The rash tends to be more concentrated on the face and extremities rather than on the trunk. It affects the face (in 95% of cases), and palms of the hands and soles of the feet (in 75% of cases). Also affected are oral mucous membranes (in 70% of cases), genitalia (30%), and conjunctivae (20%), as well as the cornea. The rash evolves sequentially from macules (lesions with a flat base) to papules (slightly raised firm lesions), vesicles (lesions filled with clear fluid), pustules (lesions filled with yellowish fluid), and crusts which dry up and fall off. The number of lesions varies from a few to several thousand. In severe cases, lesions can coalesce until large sections of skin slough off.⁷

Diagnosis:

The clinical differential diagnosis that must be considered includes other rash illnesses, such as chickenpox, measles, bacterial skin infections, scabies, syphilis, and medication-associated allergies. Lymphadenopathy during the prodromal stage of illness can be a clinical feature to distinguish monkeypox from chickenpox or smallpox.

If monkeypox is suspected, health workers should collect an appropriate sample and have it transported safely to a laboratory with appropriate capability. Confirmation of monkeypox depends on the type and quality of the specimen and the type of laboratory test. Thus, specimens should be packaged and shipped in accordance with national and international requirements. Polymerase chain reaction (PCR) is the preferred laboratory test given its accuracy and sensitivity. For this, optimal diagnostic samples for monkeypox are from skin lesions – the roof or fluid from vesicles and pustules, and dry crusts. Where feasible, biopsy is an option. Lesion samples must be stored in a dry, sterile tube (no viral transport media) and kept cold. PCR blood tests are usually inconclusive because of the short duration of viremia relative to the timing of specimen collection after symptoms begin and should not be routinely collected from patients.¹

As orthopoxviruses are serologically cross-reactive, antigen and antibody detection methods do not provide monkeypox-specific confirmation. Serology and antigen detection methods are therefore not recommended for diagnosis or case investigation where resources are limited. Additionally, recent or remote vaccination with a vaccinia-based vaccine (e.g. anyone vaccinated before smallpox eradication, or more recently vaccinated due to higher risk such as orthopoxvirus laboratory personnel) might lead to false positive results.

In order to interpret test results, it is critical that patient information be provided with the specimens including: a) date of onset of fever, b) date of onset of rash, c) date of specimen collection, d) current status of the individual (stage of rash), and e) age.

Treatment:

There are no treatments specifically for monkeypox virus infections. However, monkeypox and smallpox viruses are genetically similar, which means that antiviral drugs and vaccines developed to protect against smallpox may be used to prevent and treat monkeypox virus infections.

Antivirals, such as tecovirimat (TPOXX), may be recommended for people who are more likely to get severely ill, like patients with weakened immune systems.

If you have symptoms of monkeypox, you should talk to your healthcare provider, even if you don’t think you had contact with someone who has monkeypox.⁸

Therapeutics:

Clinical care for monkeypox should be fully optimized to alleviate symptoms, manage complications and prevent long-term sequelae. Patients should be offered fluids and food to maintain adequate nutritional status. Secondary bacterial infections should be treated as indicated. An antiviral agent known as tecovirimat that was developed for smallpox was licensed by the European Medicines Agency (EMA) for monkeypox in 2022 based on data in animal and human studies. It is not yet widely available.⁹

If used for patient care, tecovirimat should ideally be monitored in a clinical research context with prospective data collection.

Vaccination:

Vaccination against smallpox was demonstrated through several observational studies to be about 85% effective in preventing monkeypox. Thus, prior smallpox vaccination may result in milder illness. Evidence of prior vaccination against smallpox can usually be found as a scar on the upper arm. At the present time, the original (first-generation) smallpox vaccines are no longer available to the general public. Some laboratory personnel or health workers may have received a more recent smallpox vaccine to protect them in the event of exposure to orthopoxviruses in the workplace. A still newer vaccine based on a modified attenuated vaccinia virus (Ankara strain) was approved for the prevention of monkeypox in 2019. This is a two-dose vaccine for which availability remains limited. Smallpox and monkeypox vaccines are developed in formulations based on the vaccinia virus due to cross-protection afforded for the immune response to orthopoxviruses.¹⁰

Prevention:

Monkeypox can spread from the time symptoms start until the rash has fully healed and a fresh layer of skin has formed. This can take several weeks. People who do not have monkeypox symptoms cannot spread the virus to others. At this time, it is not known if monkeypox can spread through semen or vaginal fluids.

There are number of measures that can be taken to prevent infection with monkeypox virus:

· Avoid contact with animals that could harbor the virus (including animals that are sick or that have been found dead in areas where monkeypox occurs).

· Avoid contact with any materials, such as bedding, that has been in contact with a sick animal.

· Isolate infected patients from others who could be at risk for infection.

· Practice good hand hygiene after contact with infected animals or humans. For example, washing your hands with soap and water or using an alcohol-based hand sanitizer.

· Use personal protective equipment (PPE) when caring for patients.

Practice good hand hygiene after contact with infected animals or humans:

JYNNEOSTM (also known as Imvamune or Imvanex) is an attenuated live virus vaccine which has been approved by the U.S. Food and Drug Administration for the prevention of monkeypox. On November 3, 2021, the Advisory Committee on Immunization Practices (ACIP) voted to recommend JYNNEOS pre-exposure prophylaxis as an alternative to ACAM2000 for certain persons at risk for exposure to orthopoxviruses.¹¹

Reducing the risk of human-to-human transmission:

Surveillance and rapid identification of new cases is critical for outbreak containment. During human monkeypox outbreaks, close contact with infected persons is the most significant risk factor for monkeypox virus infection. Health workers and household members are at a greater risk of infection. Health workers caring for patients with suspected or confirmed monkeypox virus infection, or handling specimens from them, should implement standard infection control precautions. If possible, persons previously vaccinated against smallpox should be selected to care for the patient.

Samples taken from people and animals with suspected monkeypox virus infection should be handled by trained staff working in suitably equipped laboratories. Patient specimens must be safely prepared for transport with triple packaging in accordance with WHO guidance for transport of infectious substances.

The identification in May 2022 of clusters of monkeypox cases in several non-endemic countries with no direct travel links to an endemic area is atypical. Further investigations are underway to determine the likely source of infection and limit further onward spread. As the source of this outbreak is being investigated, it is important to look at all possible modes of transmission in order to safeguard public health.¹¹

Reducing the risk of zoonotic transmission:

Over time, most human infections have resulted from a primary, animal-to-human transmission. Unprotected contact with wild animals, especially those that are sick or dead, including their meat, blood and other parts must be avoided. Additionally, all foods containing animal meat or parts must be thoroughly cooked before eating.¹¹

Preventing monkeypox through restrictions on animal trade

Some countries have put in place regulations restricting importation of rodents and non-human primates. Captive animals that are potentially infected with monkeypox should be isolated from other animals and placed into immediate quarantine. Any animals that might have come into contact with an infected animal should be quarantined, handled with standard precautions and observed for monkeypox symptoms for 30 days.¹²

CONCLUSIONS:

Unusual cases of monkeypox are popping up all over the world. Fortunately, this virus barely has any chance of infecting people, and there are ample treatments and vaccines for it.

REFERENCES:

1. Centers for Disease Control and Prevention. Monkeypox. Accessed May 25, 2022. https://www.cdc.gov/poxvirus/monkeypox/about.html

2. World health organization (WHO). Monkeypox. Accessed May 25, 2022. https://www.who.int/news-room/fact-sheets/detail/monkeypox

3. Centers for Disease Control and Prevention (CDC). Monkeypox Treatment. Accessed May 25, 2022. https://www.cdc.gov/poxvirus/monkeypox/clinicians/treatment.html

4. Falcinelli SD, Chertow DS, Kindrachuk J. Integration of global analyses of host molecular responses with clinical data to evaluate pathogenesis and advance therapies for emerging and re-emerging viral infections. ACS Infect Dis. 2016;2(11):787-799. doi:10.1021/acsinfecdis.6b00104

5. Brown K, Leggat PA. Human monkeypox: current state of knowledge and implications for the future. Trop Med Infect Dis. 2016;1(1):8. / doi:10.1016/S1473-3099(22)00228-6 Monkeypox Outbreak — Nine States, May 2022 Centers for Disease Control and Prevention (CDC). Source: MMWR Morb Mortal Wkly Rep 2022;71:764–769.

6. Emergence of Monkeypox — West and Central Africa, 1970–2017. Centers for Disease Control and Prevention (CDC). Source: MMWR Morb Mortal Wkly Rep 2018;67:306–310.

7. Strengthening of Surveillance during Monkeypox Outbreak, Republic of the Congo, 2017. Centers for Disease Control and Prevention (CDC). Source: Emerg Infect Dis. 2018;24(6):1158-1160.

8. Reemergence of Human Monkeypox in Nigeria, 2017. Centers for Disease Control and Prevention (CDC). Source: Emerg Infect Dis. 2018;24(6):1149-1151.

9. Multistate outbreak of monkeypox—Illinois, Indiana, and Wisconsin, 2003. Centers for Disease Control and Prevention (CDC). Source: MMWR Morb Mortal Wkly Rep. 2003 Jun 13;52(23):537-540.

10. Update: multistate outbreak of monkeypox—Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003. Centers for Disease Control and Prevention (CDC). Source: MMWR Morb Mortal Wkly Rep. 2003 Jun 20;52(24):561-564.

11. Update: multistate outbreak of monkeypox—Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003. Centers for Disease Control and Prevention (CDC). Source: MMWR Morb Mortal Wkly Rep. 2003 Jun 27;52(25):589-590.

12. Update: multistate outbreak of monkeypox—Illinois, Indiana, Kansas, Missouri, Ohio, and Wisconsin, 2003. Centers for Disease Control and Prevention (CDC). Source: MMWR Morb Mortal Wkly Rep. 2003 Jul 4;52(26):616-618.

Video Link:

https://www.youtube.com/watch?v=ZRkL5PWhYBE

https://www.youtube.com/watch?v=-lHF0grhb0c

Received on 28.08.2022 Modified on 22.09.2022

Int. J. Nur. Edu. and Research. 2022; 10(4):409-414.

DOI: 10.52711/2454-2660.2022.00093